Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Wednesday, November 29, 2006

Anatomy Lesson

OK, I'm switching from bitterroot to cotton candy: let's talk TV. If confession is purifying, then it should help me to admit I watch medical shows: "Grey's Anatomy," "ER," even the ridiculous "House, M.D."

Readers of this blog know it, I'm sure; but I wonder how many people who watch Grey's Anatomy are aware of the word-play on the name of medicine's most famous anatomy text. Just asking. It's about the only way in which the show bears resemblance to reality, especially as applies to surgery training. I assume these shows have medical consultants. Wonder how much they get paid, and why the producers haven't called me...

Let's start with something mundane (OK, it's all mundane), but which I always find amusing. (Oh yeah: I also watch "Scrubs," and have wondered from the beginning why in the opening sequence JD puts the chest Xray up backwards. That's amusing, too; and puzzling. I'm thinking it's so obvious that they're doing it on purpose. But why.....?) The classic portrayal of surgery -- the actual act of operating -- is to show a surgeon (I particularly note that chief resident lady) sewing something. And without fail that surgeon tightens the suture by pulling the needle and needle-holder high above his/her head -- a regular quilting bee. In real life, raising one's hand that high is never done: for one thing, you're likely to whack it into an overhead surgical light. For another, it's clumsy as hell. Surgery is about control and stability. Which is why it's also a kick to watch the other enactments of operating: see how they hold instruments? High up on the handles, with their elbows out, hands far from the patient, as if stirring some mysterious stew? I doubt you even carve your steak that way. In the operating room, a surgeon's hands are almost never flapping around like that. You want to rest them on something firm; if not the whole hand, then at least the pinkie, like a cane. Elbows in, hands and fingers close as possible to the patient. In fact, many surgeons avoid putting fingers in the "finger-holes" of instruments, placing that part in their palm, thumb on the mid-shaft and index finger nearly all the way to the end of the instrument. You can click and unclick the lock with the pad at the base of the thumb (the thenar eminence) opposing the middle or ring finger. (Naturally, some of my teachers were adamant that you NEVER do it that way....) I'll give them this much: it's pretty rare any more to see the actors at the scrub sink with the masks off their faces. Or contaminating their hands by washing backwards.

Watching "Grey's Anatomy," you'd conclude that surgery interns hang around together until some interesting case comes up, and then they fight for who gets to be involved. Heart, belly, uterus, whatever is next. In reality, you're assigned for a given time to a given service -- vascular, cardiac, ortho, several other options -- and that's what you do until you move on in a month or two or three. And you'll likely never see anyone who's not assigned there with you, except at big conferences. Nor will you spend much time sitting around discussing (or performing) sex, or anything else. You'll be doing the work of admitting six or ten patients, in many of whose operations you'll likely not participate. You'll be running around collecting lab data, old records, Xrays. Into the wee hours, you'll be charting, writing orders, checking pre- and postop patients, taking calls for sleeping pills. Paging your superiors. And not only will you not be directly assisting the operating surgeon (and sure as hell you won't be doing the delicate parts of his operation so no one will notice his disability!! "We're a great team," he says. Give me a friggin' break, say I!), you'll be at least one body away from the action. If you live with a bunch of fellow interns, your intercourse will consist mainly of leaving notes asking whoever ate your peanut butter to please replace it. I was one of twelve surgery interns, who rotated serially through the services, like a trunk/tail elephant parade. About half were one-intern shows, which meant I neither saw any of my fellows nor my apartment for a couple of weeks at a time. On the two-intern services, I shared with the same two all year: Wendell at the front end, and Mike at the back end of each two-month alloquot. Hardly knew the others at all. Sure as hell didn't screw any of them. Or my professors. Despite that "front end - back end" reference. Not a lot of lady surgeons, them days.

Will someone please enlighten me: what the hell sort of doctors are House and his groupies? I'm not talking about assholery: that part is clear enough. I mean specialty. In no big hospital that I know of would the same people sitting around thinking off over a patient be the ones to do all those procedures. Biopsies. Radiologic interventions. Of late they've tapered off a bit from their routine breaking and entering of their patients' homes; but they still seem to be doing pretty much everything else. Moreover, what exactly is their relationship? The groupies are too old to be residents, plus the black guy was once assigned to mentor House himself. So why do they spend all that time being lectured to and ordered around? Don't they ever have something else to do? And really: I know poor ol' House is more drug-addled of late, but c'mon: not even stoned would any doctor mistake anything for four-limb necrotizing fasciitis. (Not only is there virtually no mechanism for getting it simultaneously in all four extremities, the patient would be dead too soon for a story line to develop.) It's inventive that the guy is a junkie. But after a while the formula wears thin: doctor-prick treats the patient like crap, makes about three wrong diagnoses, does a few unnecessary tests, putting the poor soul near the brink of death, then comes up with the right answer right before the closing credits. Every week, same damn thing. And yet: popular as pumpkin pie.

A quantum leap in realism was brought to the small screen with the advent of "ER," what with the roving camera and long takes; the failures, the confusion. But damn! With great regularity those patients seem to remain in the ER forever. Intubated, drugs dripping in. Like they're admitted there. Unless the ICU and recovery rooms are all overloaded, that just doesn't happen. Those guys have even opened bellies in their ER -- as big a no-no as there is. And let's not even talk about how often guns, bombs, and other disasters strike that place. Bad ju-ju. They need to see if it's built on an ancient cemetery or something. Of course, it's all about entertainment, and not reality, and since when is reality all that entertaining anyway? In the grand order of things, it's a speck in the collective eye. But geez, aren't we doctors and nurses exciting enough that you could have a good show without just making shit up out of whole cloth?

38 comments:

When I heard about the intern on Grey's Anatomy assisting the surgeon I was jealous. I just wish I could be that good of a surgeon a few months after graduating from medical school.

Maybe the reason House is so popular is that's how our patients feel: like someone runs several unnecessary tests, misses the diagnosis which is obvious to the final consultant, and endangers their life in the meanwhile. . . That's the story you often hear from someone sent for a consult, regardless of whether the previous care was appropriate.

I've honestly never seen so much as one second of House, Scrubs, or Grey's Anatomy. I watched a few episodes of ER the first couple of years, before it got too unrealistic.

I have enjoyed "Trauma: Life and Death in the ER" occasionally.

It's pretty common nowadays to have intubated patients and those with multiple drips remain in the ER for hours waiting on ICU beds, but we call in the gastroenterologist to do our endoscopies (in the ER, for esophageal impactions mainly). They call in their own nurses to assist. Pretty cool.

such a great post to set the record straight. i do find it annoying sometimes how unreal these shows are, and how the docs are morphing into daytime soap opera characters. i have to disagree about House - I routinely perform thoracostomies and spinal taps in the office all the time, just before i scrub for whipples in the back room.

One thing that occurred to me in medical school watching surgeons, was that they hold instruments in seemingly unorthodox ways, the way that artists hold drawing and painting instruments in unorthodox ways, because of the issue of control and precision.

I'm a resident in Plastics. My former chairman is well known for smacking the residents' knuckles with whatever instrument available (usually suture scissors) when he takes his fingers out of the loops. I spent a month as an intern with bruised knuckles. Now, (after four years) I'm trying to relearn how to palm instruments (when I'm not in a case with him).

E.R. is guilty of a lot of the same crimes. If you believe the show, E.R. docs can do anything: endoscopy, ICU patient management, invasive radiology, surgery, cardiac caths,E etc. In fact, if you're a surgeon in County General, you can do anything. We had Corday doing general surgery, liver transplants, spine surgery, cardiac surgery, and who knows what else.

I don't have TV set up to watch so I rent DVDs and have seen the first two seasons of Grey's Anatomy and four episodes of House (which I think is horrid). I used to faithfully watch ER but then Dr. Greene died in Hawaii. Sigh.

Food for thought on movies and the depiction of operating. Compare and contrast William Hurt in The Doctor (a bombastic CT surgeon who gets 'throat cancer' and learns how to be a patient) with Meg Ryan in City of Angels (a single female CT surgeon who bike rides through the gettos of LA to get to the hospital before she meets the angel Nicholas Cage).

In The Doctor, William Hurt is seen just as described in a catastrophic 'aortic dissection', fumbling with the needle driver and loading and reloading the needle up by the light handles. In City of Angels, Meg Ryan actually was shown in arms in body posture, wearing loops, rhytmically using an appropriate sized castro-viehjo with a reasonable appearence of fluid efficiency.

I confess to being part of the Grey's Anatomy cult. What would really happen to someone if they cut a patient's LVAD wire? Would they lose their career as a surgeon?

I worked in ED registration for the last 20 years until recently and have thoroughly enjoyed working with the staff and patients. There is always something interesting going on in a hospital. :) I have worked around a lot of surgeons and heard their interesting stories, etc., but until Grey's Anatomy - never really thought much about all the training they have had and what they had to go thru to get to where they are now.

I recently purchased your book, which I am enjoying and also recently read your Oct.7th post called "Taking Trust". I was so moved by that post,in awe really. It was eloquently written and you are truly a gifted writer.

At that time, I was thinking I was going to have surgery, but thanks to my skilled and dedicated urologist it turns out that everything he did has worked and I won't have to go thru it after all.

I was profoundly affected by that post (Taking Trust) and even reassured that a surgery could mean so much to a doctor, affecting him or her to the very core of their being, so much so, that it would even feel sacred. Thank you for writing that post.

Hear hear for Scrubs. Although Scrubs is a vehicle for comedy rather than drama, and doesn't pretend to take itself as seriously as those other shows..I concur with 'dk' that it's probably the closest to reality, and has far greater depth.

As per SusanRN, I agree it also has far greater breadth of characterisation of the hospital environment...and doctors are in reality but a fraction of the staff involved in patient care.

I personally have been in the ER for many hours when I had the misfortune to be low on the triage pole behind two head on car crashes. But the rest of it is just pure intertainment. What fun would it be if they were total strangers and not sleeping with each other? Actually the discovery channel does reality medical shows, but you really have to be a nerd to watch them. And you forgot to mention Dr. 90210. Dr. Reyes is a real pig and he doesn't even have to make stuff up.

Hmmmm, as addicted to medblogs as I am, the only one of these shows that I have actually watched is ER, and I have only seen a few episodes. If they bother you so much, why do you continue to watch? I'm sure you have better things to do . . .

1. I really like Scrubs too. The juxtaposition of silliness with *abject fear* resonates.

I think it grabbed me in one of the very first eps when JD was standing in a patient's room, bad news, and took a delivery of "Ton of bricks for Dr. Dorian?"

I like all these medical dramas, back to M*A*S*H*, Quincy ME and St Elsewhere.

Jozi-H is a Canada-South Africa co-production; it *doesn't so much take place in Chicago.* Still kind of soapy (that's TV for you) but different um, suds?

2. As a cc4 I just assumed the CXR was backwards b/c they were interns. And felt *very* clever pointing that out to non-medical friends and family.

TV has its pluses.

3. Then there was the night a year later, as an R1 in emerg, during SARS. Husband end-stage CAD/MI, wife says: "It's not as exciting as it is on TV." All of us and hubby stare at her. "Well, there's no music or anything." For us (and hubby I'm sure) it was exciting enough without the music.

4. A show about family practice would really suck. Even with music and suds.

I enjoy Scrubs too and I forgot about Mash. I loved that show! My joke has always been that working with the emergency staff was like Mash because when it was crazy you worked really hard and when it wasn't, we were crazy! You have to have a sense of humor! I think there could be a lot of material with a private practice show. Remember Marcus Welby MD? (I wanted to be Consuela - helping people) I think there could be both humor and drama - every profession has some stories!

God, ya'll must be young..Give me Dr. Kildare. Noone played it better than Richard Chamberlain.

I have never watched these shows you are talking of, other than ER. But, even that, I haven't watched since George Clooney left, many seasons ago.

When I was, (cough) young, there use to be a song about Dr. Kildare, based on the baseball song. Want me to sing it for ya?

To late if you say NO because I'm already singing it!

~~~Take me out to the hospital, wheel me up to my room, stick me with needles, for I don't care, I'm in looooove with Dr. Kildare. And it's boo boo boo for Ben Casey, Rah Rah Rah for Kildare, and it's one, two, three shots your out at the old hos....pital....pital...pital...pital...cha...cha...cha!~~~

There's a new medical melodrama (I think on CBS) called '3 lbs'. It's about two neurosurgeons, one older and cynical, the other young and earnest. There's also a fetching neurologist thrown in for good measure.

I couldn't make it through one episode, and I'm just a patient. One of the subplots involved the younger surgeon going to bed with a patient's sexy lawyer (NO!!!! Doctors hate lawyers.) The lawyer uses her wiles to weasel out information from the surgeon. She then drops him like a hot potato (Ha Ha). He's devastated (so sad).

For me, the only redeeming feature is the older surgeon is played by Stanley Tucci, a fine actor who brings some subtlety to his character.

I've watched House a couple of times. The plots look far-fetched. I am, however, amazed at how well Hugh Laurie, a British actor, can speak with an American accent.

I like House because I like Hugh Laurie. As Anon 2:18 said, it's amazing how Laurie can carry this off - obviously a very accomplished actor. (If you want to see him in a very different show - watch Black Adder III. This is a Brit comedy with Roman Atkinson, where Laurie plays a stuffy prince.)

You have to suspend reality a bit to watch these shows. Otherwise you will go crazy.

Maybe you docs think all these shows are unrealistic, but it's not clear to me that docs are often not guessing when they diagnose patients. I was ill last year for about 8 weeks, and just went from one specialist to another with no definitive diagnosis. I started getting better, and the diagnosis was "some kind of virus".

Anonymous 3.58pm: as unusual as it may sound, sometimes doctors just can't figure out what's going on. We're only human; there are actually patients whose conditions have us stymied.

And yep, Hugh Laurie is brilliant and is one of my inspirations. Black Adder is a classic here in England, as is Jeeves & Wooster. Laurie started off in my university, where he was already a hit. Glad House has given him an international stage :)

There's also 'Nip/Tuck', the show about plastic surgeons in Miami Beach. The show's more about the surgeons' personal lives; it's more like a soap opera with a little bit of plastic surgery procedures added on.

Some of it seems odd. They showed one of the surgeons getting liposuction (even though he looks mighty trim). He was completely awake during the procedure. I was under the impression you had to be asleep for this.

One eye-catching part of the show are the sex scenes, featuring various positions and a decent amount of male nudity. These scenes are just shy of softcore porn; the only thing missing is the cheesy porn music.

I like the medical stuff in these shows but hate the soap opera aspects. I stopped watching ER because it started to seem like everyone on the show was sleeping with everyone else. I tried Grey's Anatomy once but it appeared to be about 90% soap so I gave up on it. (The acting was alao pretty bad.)

House is fun because Hugh Laurie is so good and all the cases are obscure. With House you should think "unicorn" when you hear those hoofbeats, not "zebra" or "horse". It's fun to see if you can beat them to the dianosis. That said, sometimes the cases are painfully obvious: Who can see bats in an alley and not think "rabies" and even if House was so addled by withdrawl to diagnose necrotizing fasciitis in multiple limbs, don't any of the other docs have brains?

Unfortunately House appears to be heading down soap opera lane as well with each season having a new backstory involving some bad guy out to get House. The cases aren't as interesting as they used to be either.

McDreamy Eyes! And of course the med stuff is interesting, even if not realistically carried out. Also, with this week's siames twin story - I never thought about siamese twins physically/verbally fighting with each other.

On last weeks ER, I noticed that after "gloved" Dr. Pratt put the container of body fluid on Jerry's (ward clerk) desk that he didn't put gloves on before picking it up to take to the lab. Infection control? OSHA?

You know, I used to NEVER miss an episode of ER, that is, until I got into medical school. I've heard of "ER clubs" in various med schools, but I don't know how anyone has the time for that. Once I broke my ER habit, I lost interest in the medical dramas. Guess I got enough of that at work.

I'm beginning to come around now, though. I recently started watching "Scrubs"--what a hoot! I just love that Dr. Cox!!! He reminds me a great deal of one of my attendings.

I am a big fan of Scrubs and House, not so much of ER or Grey's Anatomy. I don't think it's fair to ask a television show to accurately portray surgery, but I can see how those errors would irk someone whose job it is to do it correctly.

The formulaic approach that House, MD takes would usually not hold up a show. If it weren't for Hugh Laurie's incredible skill and wit, and that of the supporting cast, I don't think the show would be popular at all. Also, in response to your question, House's primary specialty, IIRC, is nephrology. I believe they have referred to him as the nation's top diagnostician on the show - not sure if that qualifies as an actual specialty outside of TV land, though....

I can't stand House. It barely qualifies as a medical show. All anybody has to do is look up an obscure disease in Harrison's or whatever, and then construct a screenplay around it, working backwards. But such canned writing is not the biggest sin--that lies with the fact that not a single character has any redeeming qualities whatsoever. I couldn't care less if any of them contracted Ebola and bled out on the show. In fact, I think that would get me to tune in.

Scrubs is great because as others have said, it doesn't take itself seriously and really does involve lots of facets of hospital life, not just the 20-something angst of a group of shallow interns (now PGY2s, I suppose) a la Grey's Anatomy. That being said, at least GA's characters, while shallow and not exactly complex, at least resemble real people in real situations (in life, not in hospital) and display a full spectrum of emotions, unlike the House crew, who I feel are ready to knife each other at a moment's notice when the other isn't looking. Just like well-trained pre-med students.

It's kind of stupid (not to mention a waste of time) to keep analizing medical TV shows by their commitment with the truth. They are made for entertainment and even if it seems like an important part of these shows, Medicine is only a (luxury) supporting elemen.

Yes, House is made of a formula. But what makes it AMAZING is the writting: the dialogues are well-built, smart and touching. If you are a doctor and never questioned something about your thoughts after seeing an episode of House, then you're a flat and narrow-minded person.

About Grey's Anatomy, it's almost a soap opera and Medicine is really secondary, although it's good for the metaphores. The show is about relationships not a guide on how to make a surgery. Imagine how boring it would be to watch a single intern (instead of a group) that almost never goes to the OR, just to keep it real. Real sucks sometimes...

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.